Provider Demographics
NPI:1336212570
Name:SHEA, JENNIFER (ANP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SHEA
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7700 WASHINGTON VILLAGE DR
Mailing Address - Street 2:STE 230
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4094
Mailing Address - Country:US
Mailing Address - Phone:937-376-2571
Mailing Address - Fax:937-376-2930
Practice Address - Street 1:7700 WASHINGTON VILLAGE DR
Practice Address - Street 2:STE 230
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4094
Practice Address - Country:US
Practice Address - Phone:937-376-2571
Practice Address - Fax:937-376-2930
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK785363LA2200X
OHNP-10736363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNP9648Medicaid
AK02D0640596OtherCLIA#
AKP99903Medicare UPIN
AK02D0640596OtherCLIA#